COPD

Question 1

GOLD GRADE

Answer 1

GOLD grade
A. B. C. D

mMRC breathlessness
0-1. >=2. 0-1. >=2

Exacerbations in past year
<2. <2. >=2. >=2

Question 2

The mMRC scale:

Answer 2

Grade Exacerbations in past year

0. Dyspnea with strenuous exercise
1. Dyspnea when hurrying on level ground or walking up a slight hill

2 Walks slower than people of same age group, due to dyspnea

3 Stops for breath after walking 91m, or after a few minutes on level ground

4 Too breathless to leave the house, or dyspnea when dressing/undressing

Question 3

GENERAL MEASURES

Answer 3

1. Patients with clinical COPD must undergo spirometry to confirm and grade the severity of obstruction.
2. Patients should be screened for ongoing smoking and advised to stop at each visit.
3. Smoking cessation and avoidance of noxious respiratory particles should form the mainstay of management.
4. Vaccinationsfor:
   a) Pneumococcal pneumonia
   B) Influenza
5. Pulmonary rehabilitation:
   a) Guided exercise and behavioral interventions b) Goal is to improve functional capacity.
6. O2 therapy:
   a) If O2 saturation is < 88% in a stable patient (PO₂ < 55 mm Hg)
   b) If concurrent pulmonary hypertension, right-sided heart failure, or polycythemia

Question 4

Medicine Management

Answer 4

Salbutamol, nebulisation, 5 mg.
Nebulise continuously (refill the nebuliser reservoir every 20 minutes) at a flow rate of 6–8 L/minute.
If a poor response to nebulised salbutamol:

ADD

Ipratropium bromide 0.5 mg (UDV) with the first refill of the nebuliser reservoir.
Patients who fail to respond within 1 hour must be discussed with a specialist. (Patients with COPD have fixed airway disease and unlike asthmatics, PEF is not a reliable measure of their disease).
Once clinically stabilised, nebulise with:

Salbutamol, nebulisation 5 mg OR fenoterol 1.25–2.5 mg.
Repeat 4–6 hourly.
AND

Corticosteroids (intermediate-acting) e.g.:
Prednisone, oral, 40 mg immediately.
Follow with:

Prednisone, oral, 40 mg daily for 5 days.
LoEI [24]

OR

In patients who cannot use oral therapy:

Hydrocortisone, IV, 100 mg 6 hourly until patient can take oral medication.
Once oral medication can be taken, follow with:

Corticosteroids (intermediate-acting) e.g.:
Prednisone, oral, 30 mg daily for 5 days.
Monitor response and clinical signs.

Question 5

Management of Acute Infective Exacerbation Of Chronic Bronchitis:

Answer 5

Amoxicillin, oral, 500 mg 8 hourly for 5 days.
Severe penicillin allergy: (Z88.0)

Doxycycline, oral, 100 mg 12 hourly for 5 days.
Non-responsive to first course of antibiotic therapy or in patients with a moderate to severe exacerbation and who have increased sputum purulence plus ≥ 1 of the following symptoms should receive an antibiotic:

increased dyspnoea,
increased sputum volume
Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

Severe penicillin allergy: (Z88.0)

Azithromycin, oral, 500 mg daily for 3 days.

Question 6

3 Management of Chronic Therapy

Answer 6

Chronic Therapy

GRADE A

As initial therapy:

Short acting β2-agonist (SABA) e.g.:
Salbutamol, MDI, 200 mcg 6 hourly as needed (educate on correct inhaler use - use a large volume spacer if inhaler technique remains poor).
If no response in symptoms or GRADE B:

LoEIII [28]

ADD

Long acting β2-agonist (LABA), e.g.:
Formoterol, inhalation 12 mcg 12 hourly.
LoEI [29]

GRADE C and D (frequent exacerbations (≥2 per year)):

Short acting β2-agonist (SABA) e.g.:
Salbutamol, MDI, 200 mcg 6 hourly as needed using a large volume spacer.
AND

LABA/ICS combination, e.g.:
Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.
LoEI [30]

AND
Refer COPD patients for additional assessment and management.

Patients on protease inhibitors:

Replace salmeterol/fluticasone with:

Beclomethasone, inhalation, 400 mcg 12 hourly.
LoEIII [31]

AND

Formoterol, inhalation, 12 mcg 12 hourly.
If inadequate control with above therapy:

Theophylline, slow release, oral, 200 mg at night. Specialist consultation.
Ongoing use of theophylline should be re-evaluated periodically. If there is no benefit after 12 months discontinue theophylline.

Question 7

SYMPTOMS

Answer 7

Patients suffer from chronic, progressive symptoms with acute exacerbations.

1. General:

Progressive dyspnea (particularly with exertion)
Chronic cough
Sputum production
Chest tightness
Weight gain or loss
Fatigue

2. Acute exacerbation:

Worsening dyspnea
Increased cough 
Purulent sputum production
Wheezing
Fever may or may not be present

Question 8

PHYSICAL EXAMINATION

Answer 8

When examining a patient with possible COPD, look for the following findings:

1.Vitals:

Tachypnea
Hypoxia

2. General:

Muscle wasting
Barrel chest: increased anteroposterior chest wall diameter from hyperinflation

3. Pulmonary:

Inspection:
Respiratory distress (acute exacerbations)
Accessory muscle use
Pursed lip breathing

Auscultation:
Prolonged expiration
Wheezing
Diminished breath sounds

Palpation and percussion:
Hyperresonance on percussion
Reduced chest wall expansion

Extremities:

Digital clubbing
Cyanosis

Findings suggestive of cor pulmonale:

Jugular venous distension
Peripheral edema

Question 9

Clinical Phenotype

Answer 9

Signs and symptoms are associated more frequently with either chronic bronchitis or emphysema. However, patients often present with a mixture of features.

Chronic bronchitis (“blue bloater”):

Patients are generally overweight.
Frequent, productive cough
Peripheral edema
Cyanosis
Emphysema (“pink puffer”):

Patients are generally thin.
Barrel chest
Infrequent cough
Pursed lip breathing
Accessory muscle use
Tripod positioning
Hyperresonant chest